术前选择性门静脉栓塞在大肠癌肝转移患者中的应用

大肠癌多发性肝转移灶切除后剩余肝脏组织太少,易导致术后肝功能不全或肝功能衰竭,限制了手术的应用。术前门静脉栓塞术(PVE)通过使栓塞侧肝叶萎缩,诱使对侧肝叶代偿性增生肥大,使原来不能耐受肝切除的患者能够安全地接受手术治疗。现综述术前选择性门静脉栓塞术在大肠癌肝转移应用中的病理生理学基础、临床适应证及疗效。     

Portal vein embolization failure: Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection

Portal vein embolization (PVE) is currently considered the standard of care to improve the volume of an inadequate future remnant liver (FRL) and decrease the risk of post-hepatectomy liver failure (PHLF). PHLF remains a significant limitation in performing major liver surgery and is the main cause of mortality after resection. The degree of hypertrophy obtained after PVE is variable and depends on multiple factors. Up to 20% of patients fail to undergo the planned surgery because of either an inadequate FRL growth or tumor progression after the PVE procedure (usually 6-8 wk are needed before surgery). The management of PVE failure is still debated, with a lack of consensus regarding the best clinical strategy. Different additional techniques have been proposed, such as sequential transarterial chemoembolization followed by PVE, segment 4 PVE, intra-portal administration of stem cells, dietary supplementation, and hepatic vein embolization. The aim of this review is to summarize the up-to-date strategies to overcome such difficult situations and discuss future perspectives on improving FRL hypertrophy.     

The efficacy of portal vein embolization prior to right extended hemihepatectomy for hilar cholangiocellular carcinoma: A retrospective cohort study

Background/Purpose

Preoperative portal vein embolization was introduced to minimize complications after extended hepatectomy. This retrospective cohort study was conducted to compare outcomes with and without portal vein embolization before hepatectomy for hilar cholangiocellular carcinoma.

Methods

This study was conducted with 35 patients who underwent right extended hemihepatectomy for hilar cholangiocellular carcinoma from 2001 to 2008. Preoperative portal vein embolization was performed in 14 patients (embolization group) and not performed in 21 patients (non-embolization group).

Results

The groups did not differ in terms of sex, age, operative time, transfusion, postoperative serum bilirubin level, prothrombin time, and length of intensive care unit (ICU) stay. Although blood loss was higher in the embolization group than in the non-embolization group (P = .009), no major complications were observed between embolization and resection. At presentation, future liver remnant was smaller in the embolization group (19.8%, range 16-35%) than in non-embolization group (28.3%, 15-47%; P = .001). After embolization, the volume of the future liver remnant increased significantly to 27.2% (range, 23-42%; P = .001). Future liver remnants just before operation were similar in both groups (P > .99). There was no significant difference in terms of the rate of morbidity and in-hospital mortality. No statistically significant differences were observed in disease-free survival (P = .52) and overall survival (P = .30).

Conclusions

Portal vein embolizations do not increase the rate of morbidity, in-hospital mortality, local recurrence and system metastasis. Therefore it can be considered safe and effective for patients with small future liver remnants. Embolization can lessen postoperative liver failure and widen the indication of the surgical resection, especially in patients with marginal future liver remnants.     

Sequential therapy of portal vein embolization and systemic chemotherapy for locally advanced perihilar biliary tract cancer

BackgroundCurative resection is the only potential treatment for cure in patients with perihilar biliary tract cancer (PBTC). However, post hepatectomy liver failure (PHLF) due to insufficient future liver remnant volume (FRLV) remains a lingering risk even after portal vein embolization (PVE). This study aimed to investigate the feasibility and efficacy of a sequential treatment strategy consisting of PVE followed by preoperative chemotherapy before surgery.MethodsBetween April 2019 and December 2021, 15 patients with locally advanced PBTC (LA-PBTC) underwent sequential treatment consisting of PVE followed by preoperative chemotherapy. The feasibility and efficacy, including resection rate, changes of FRLV, and chemotherapeutic effect, were investigated retrospectively.ResultsThirteen of 15 patients (86.6%) underwent curative resection. The median duration time between PVE and surgery was 144 days. FRLV/TLV ratio was 31.3% at prePVE, 38.4%, at two weeks after PVE, and 45.7% before surgery, respectively. There was significant increase in FRLV/TLV ratio two weeks after PVE. Additional increase in FRLV/TLV ratio was significantly achieved before surgery. PHLF occurred in 5 patients (38.4%). Pathological complete response was found in 2 of 13 patients (15.3%).ConclusionsSequential PVE and systemic chemotherapy contribute to the sufficient hypertrophy of FRLV without compromising resectability in patients with LA-PBTC.     

Portal vein embolization effect on colorectal cancer liver metastasis progression: Lessons learned

Colorectal liver metastasis (CRLM) is the major cause of death in patients diagnosed with colorectal cancer. The gold standard treatment of CRLM is surgical resection. Yet, in the past, more than half of these patients were deemed unresectable due to the inadequate future liver remnant (FLR). The introduction of efficient portal vein embolization (PVE) preoperatively allowed more resections of metastasis in CRLM patients by stimulating adequate liver hypertrophy. However, several experimental and clinical studies reported tumor progression after PVE which critically influences the subsequent management of these patients. The underlying pathophysiological mechanism of tumor progression post-PVE is still not fully understood. In spite of the adverse effects of PVE, it remains a potentially curative procedure in patients who would remain otherwise unresectable because of the insufficient FLR. Currently, the challenge is to halt tumor proliferation following PVE in patients who require this technique. This could potentially be achieved by either attempting to suppress the underlying oncologic stimulus or by inhibiting tumor growth once observed after PVE, without jeopardizing liver regeneration. More research is still required to better identify patients at risk of experiencing tumor growth post-PVE.     

Fast-track two-stage hepatectomy by concurrent portal vein embolization at first-stage hepatectomy in hybrid interventional radiology / operating suite

ObjectivesIn two-stage hepatectomy for bilateral liver metastases, patient dropout between stages is a major issue. We recently proposed a novel approach of fast-track two-staged hepatectomy (FT-TSH), in which patients undergo concurrent first-stage hepatectomy (FSH) with portal vein embolization (PVE) in a hybrid interventional radiology surgical suite. However, its efficacy remains unclear.MethodsPatients with bilateral liver metastases scheduled for FT-TSH at MD Anderson Cancer Center between October 2017 and December 2020 were included on a prospective registry. The effectiveness and feasibility were evaluated.ResultsNineteen patients were scheduled for FT-TSH. Primary site of tumor was colon/rectum in 18 patients and ovary in one patient. Median number of tumors was 10 and median size of largest tumor before surgery was 2.4 cm. Two (11%) patients did not undergo PVE and seventeen patients (89%) completed FSH + PVE. None of the patients had a major complication (Clavien-Dindo grade ≥ III) after FSH + PVE. Median kinetic growth rate after FSH + PVE was 2.9%/week (range 0.8–5.6). Twelve patients (71%) among the seventeen who underwent FSH + PVE proceeded to second-stage hepatectomy, and ten patients (59%) finally completed second-stage hepatectomy. Median interval between stages was 5.6 weeks (4.0–20.1). One patient (10%) had a major morbidity after SSH, and there was no 90-day mortality.ConclusionsFT-TSH is safe and allows for short intervals between hepatectomy stages while achieving favorable liver hypertrophy. Further investigation is needed to evaluate the true efficacy of FT-TSH.     

Trans-ileocecal portal vein embolization as a preoperative treatment for right trisegmentectomy with caudate lobectomy

BACKGROUND AND OBJECTIVES: The indication of preoperative portal vein embolization (PVE) has been expanded to hepatocellular carcinoma, cholangiocellular carcinoma (CCC), hepatic metastasis, and gallbladder (GB) cancer as well as hilar cholangiocarcinoma (hCC). However, biliary cancers sometimes cause peritoneal dissemination. PATIENTS AND METHODS: We performed our preoperative trans-ileocecal-vein PVE (TIPE) method on 14 (3 GB cancer, 1 CCC, and 10 hCC), whose estimated residual liver volume was <30%. RESULTS: Out of 14 patients, peritoneal dissemination was encountered in two patients with GB cancer and one with hCC (21.4%) during our procedure. The estimated residual liver volume was 37.4 +/- 2.7% at 14 days after PVE in patients without predisposing cholangitis, while those in patients with cholangitis was 29.3 +/- 1.3% (P = 0.0002). No major complication due to the procedure was encountered in this series. CONCLUSIONS: PTPE could be the first choice for patients with hCC, hepatocellular carcinoma, and hepatic metastases. Although the TIPE proposed here has some potential disadvantages, we would recommend it especially for patients with GB cancer because of its high potential to cause cancerous peritonitis. When a patient had predisposing cholangitis, radical operation should be scheduled on >21 days after PVE rather than on 14 days.     

ALPPS与门静脉栓塞治疗未来剩余肝脏体积不足肝癌临床疗效的Meta分析

目的:探讨联合肝脏分隔和门静脉结扎的分阶段肝切除术（associating liver partition and portal vein ligation for staged hepatectomy,ALPPS）和门静脉栓塞（portal vein embolization,PVE）两种术式治疗未来剩余肝脏（future liver remnant,FLR）体积不足肝癌的可行性、安全性和有效性。方法:通过检索PubMed、Web of Science、Embase、Cochrane、中国知网、万方、维普数据库中有关ALPPS与PVE治疗FLR不足肝癌临床疗效对比的所有文献,检索时间为数据库建库至2021年05月。采用RevMan 5.3软件对数据进行分析。结果:共纳入17篇文献,含1 145例患者。进行荟萃分析后显示:在二步手术完成率（OR=9.62,95%CI:5.35～17.28）、R0切除率（OR=2.01,95%CI:1.05～3.83）方面ALPPS组与PVE组之间的差异具有统计学意义（P<0.05）,ALPPS组可显著改善患者的二步手术完成率及R0切除率;在90天病死率、术后肝功能衰竭率、总体并发症发生率、3年生存率方面ALPPS组与PVE组之间的差异无统计学意义（P均>0.05）。结论:ALPPS相较PVE在治疗FLR不足肝癌时可显著改善患者的二步手术完成率及R0切除率,且两者有相似的围手术期疗效及肿瘤学结局。     

Assessment of future remnant liver regeneration after portal vein embolization using three‐dimensional CT and MR volumetric analyses

The purpose of this study is to portray right portal vein embolization (PVE) as a valuable technique that helps in expanding the volume of the left liver lobe and discuss the relevant published work. We describe our experience with four patients who underwent PVE and analyse the value of CT and MRI in the preoperative evaluation of these patients. Four patients with hepatic malignancy (hepatocellular carcinoma) (n = 2) and metastatic liver disease (n = 2) underwent portal vein occlusion. PVE was carried out in three patients using polyvinyl alcohol and stainless steel coils. Portal vein ligation was carried out in the fourth patient. In patients who were candidates for right hepatectomy, CT volumetric analysis was carried out before the surgery to assess the total liver volume and the future remnant liver, which is the residual left hepatic volume (in cases of right hepatectomy) or left lateral segment volume (in cases of right tri‐segmentectomy). Because the left lobe volumes were insufficient, patients were selected to undergo right PVE. Computed tomography volumetry was carried out 2–4 weeks after embolization to assess left hepatic lobe regeneration. Magnetic resonance volumetric analysis was carried out in two patients before and after embolization. All four patients had significant regeneration of the left lobe and tolerated the surgery with uneventful postoperative recovery.     

The role of portal vein embolization in the surgical management of primary hepatobiliary cancers. A systematic review

Background

Primary liver and biliary cancers are very aggressive tumors. Surgical treatment is the main option for cure or long term survival. The main purpose of this systematic review is to underline the indications for portal vein embolization (PVE), in patients with inadequate future liver remnant (FLR) and to analyze other parameters such as resection rate, morbidity, mortality, survival after PVE and hepatectomy for primary hepatobiliary tumors. Also the role of trans-arterial chemoembolization (TACE) before PVE, is investigated.

原发性肝癌合并门静脉癌栓的放射治疗进展

原发性肝癌合并门静脉癌栓的发病率相当高,治疗效果差、生存期短、合并症多,一直是肝癌研究领域中重要且难度高的课题。近年来放射治疗运用于原发性肝癌合并门静脉癌栓的报道越来越多,包括三维适形放疗、立体定向放疗、质子放疗、同位素内放疗以放疗为主的综合治疗等,主要根据患者的病情及癌栓情况合理制定治疗措施,进行个体化和序贯性的治疗。本文就放射治疗原发性肝癌合并门静脉癌栓的相关研究进展作一综述。     

Does portal vein embolization prior to liver resection influence the oncological outcomes – A propensity score matched comparison

Introduction

There is an ongoing controversy surrounding portal vein embolization (PVE) regarding the short-term safety of PVE and long-term oncological benefit. This study aims to compare survival outcomes of patients subjected to major liver resection for colorectal liver metastases (CRLM) with or without PVE.

高强度聚焦超声治疗门脉癌栓的初步临床观察

目的:探讨高强度聚焦超声(HIFU)治疗肝癌门脉癌栓的临床疗效。方法:6例门脉癌栓行HIFU治疗,观察患者治疗前后的临床症状和影像学变化来评价HIFU的临床疗效。结果:6例患者门脉癌栓均缩小或消失。结论:HIFU是一种有效和安全的治疗门脉癌栓的方法,为临床治疗门脉癌栓提供了一种新的手段。     

电化学治疗联合化疗泵植入治疗肝转移癌的临床研究

目的　电化学治疗 (ECT)联合门静脉系局部区域化疗治疗肝转移癌的疗效评估。方法　 4 0例肝转移癌患者随机分成两组 ,A组门静脉系植入化疗泵化疗配合ECT治疗 ,B组单纯门静脉系植入化疗泵化疗。结果　A组 7例患者完全缓解 (CR) ,7例部分缓解 (PR) ,有效率 (CR +PR) 70 %。B组CR患者 0例 ,PR患者 5例 ,有效率 2 5 %。两组CEA、CA199指标及血清免疫球蛋白效价的变化有明显差异。结论　ECT联合门静脉系区域化疗治疗肝转移癌 ,提高了缓解率和近期生存率。     

Prediction of portal vein invasion by hepatocellular carcinoma: a correlations between portal vein tumor thrombus and biochemical tests.

Hepatocellular carcinoma patients were categorized into three grades according to the extent of portal vein invasion by the tumor. Correlations between the extent of portal vein invasion and values of alpha-fetoprotein (AFP), and various biochemical tests were examined. The extent of portal vein invasion by the tumor significantly correlated with the values of glutamic oxaloacetic transaminase (GOT), glutamic oxaloacetic transaminase: glutamic pyrubic transaminase (GOT:GPT), lactic dehydrogenase (LDH), alkaline phosphatase, leucinaminopeptidase (LAP), gamma-glutamic transpeptidase (gamma-GTP) and log10AFP. Results of the multivariate logistic regression analysis showed the values of LAP, LDH, log10AFP and GOT:GPT to be statistically significant independent indicators of portal vein invasion by hepatocellular carcinoma. The calculated probability for portal vein tumor thrombus, which was derived from the results of a step wise multivariate logistic regression procedure, revealed high accuracy and specificity for predictability. To design effective therapy and to predict the prognosis, it would be beneficial to obtain additional information from this calculated probability in patients with hepatocellular carcinoma.     

肝癌合并门静脉癌栓的研究

门静脉癌栓(PVTT)是影响肝癌患者预后的重要因素.PVTT的形成是一个多因素、多环节的过程.根据门静脉的解剖特征及癌栓的生长规律,将PVTT分为Ⅰ～Ⅳ型.手术治疗、介入治疗、放疗为主的综合治疗模式提高了疗效.